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Next-Day Discharge Seems OK for Select TAVR Patients

Next-Day Discharge Seems OK for Select TAVR Patients

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Action Points

  • Excluding patients with complications, patients who had next-day discharge after transfemoral transcatheter aortic valve replacement (TAVR) had similar 30-day and better 1-year clinical outcomes (readmission and mortality) compared with non-next-day discharge patients.
  • The superiority in outcome stemmed from fewer noncardiovascular-related readmissions in the next-day discharge group; otherwise there was no statistical difference between next-day discharge and non-next-day discharge groups in terms of mortality or cardiovascular readmissions.

Leaving the hospital the day after transfemoral transcatheter aortic valve replacement (TAVR) appeared safe for certain patients at one center, researchers reported in an observational study.

Excluding cases with complications, 30-day combined mortality and readmission rates were essentially the same whether patients stayed one night or longer (6.1% versus 12.0%, adjusted HR 0.62, 95% CI 0.20-1.91), according to the study in JACC: Cardiovascular Interventions.

Yet the composite outcome was less likely at 1 year with next-day discharge (15.2% versus 30.8%, adjusted HR 0.47, 95% CI 0.27-0.81), Vasilis Babaliaros, MD, of Emory University Hospital in Atlanta, and colleagues found.

The superiority stemmed from fewer noncardiovascular-related readmissions in this group (4.6% versus 14.5%, adjusted HR 0.31, 95% CI 0.12-0.76) — otherwise, no statistical difference existed between groups in terms of mortality (1.5% versus 5.1%, adjusted HR 0.71, 95% CI 0.12-4.19) or cardiovascular readmissions (9.1% versus 14.5%, adjusted HR 0.68, 95% CI 0.33-1.43).

“When compared with patients without complications with a longer hospital stay, next-day discharge appears to be safe, achieving similar 30-day and superior 1-year clinical outcomes,” Babaliaros’ group concluded.

That’s still up for debate, however, as suggested by an editorial comment by Molly Szerlip, MD, of Heart Hospital Baylor Plano in Texas.

That noncardiovascular admissions drove superiority at 1 year “merely reemphasizes that the next-day discharge patients in this study were lower risk rather than that they benefited by next-day discharge,” she argued. Indeed, this arm of the study was slightly younger and had lower STS PROM scores at baseline (5.5% versus 7.4%, P<0.001).

Additionally, the total cohort included 663 consecutive recipients of elective TAVR with balloon-expandable devices from 2014 to 2016. After exclusions, clinical outcomes were analyzed for only 150 who had next-day discharge and 210 who had longer hospital stays, however.

“This report studied a highly selective patient population from the overall pool of patients,” according to Szerlip. “Patients excluded from the analysis were anyone who had a general anesthetic, a complication, received a self-expanding valve, or did not have a pre-procedure 3-dimensional multidetector CT.”

Babaliaros’ group found that the predictors of next-day discharge were:

  • Male sex: OR 2.02 (95% CI 1.28-3.18)
  • Absence of atrial fibrillation: OR 1.62 (95% CI 1.02-2.57)
  • Serum creatinine: OR 0.71 per 1.0 mg/dL (95% CI 0.55-0.92)
  • Age: OR 0.95 per year (95% CI 0.93-0.98)

TAVR was deemed minimalist in all cases, being performed via transfemoral access and under conscious sedation and local anesthesia.

Szerlip called this an “overly narrow definition of the minimalist approach.”

“All aspects of patient care should be minimized as long as it does not adversely affect patient outcomes,” she stated. “For example, patients undergoing TAVR under general anesthesia can still be extubated in the operating room, enter the same care pathway, and be discharged the next day.”

“We have also found that most patients can safely undergo TAVR without pulmonary artery catheters, urinary catheters or narcotics — all of which are major factors precluding routine next-day discharge. In my experience, elimination of these factors as well as setting next-day discharge expectations with the patient and their family at the time of the initial visit before the procedure and early post-procedure mobilization (within 4 hours post-procedure) are major components of a minimalist approach care pathway,” the editorialist added.

Since the point of a minimalist approach to TAVR is to get rid of all the nonessential components of care that encumber recovery without jeopardizing safety, that is the real goal — not next-day discharge, which may result from this type of care, Szerlip suggested.

Babaliaros disclosed relevant relationships with Abbott Vascular and Edwards Lifesciences.

Szerlip disclosed relevant relationships with Edwards Lifesciences and Medtronic.

2018-01-15T14:00:00-0500

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